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HomeMy WebLinkAbout0026 MOCO ROAD - Health 26 MOCO ROAD,W. BARNSTABLE A = 215 009 00 � III i i ° o o . - TOWN OF BARNSTABLE LOCATION nG !� /v<d L'0D C� %© �Et� . .0 SEWAGE # 117 VILLAGE_ ASSESSOR'S MAP & LOT 0 INSTALLER'S NAME&PHONE NO. Jylel,fit SEPTIC TANK CAPACITY / / LEACHING FACILn Y:.(type) 4 �S'S' og o ft'�l ®�izeri lG m—) NO. OF BEDROOMS 3 " BUILDER OR OWNER /L!J PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist f on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If.any wetlands exist within 300 feet of leaching facility) Feet Furnished by c-1� ll _ f of - L' 0 0 �o�►G po r Massachusetts Department of Environmental Protection Bureau of Resource Protection Well Completion Reports Well Driller Please specify work performed: Address at well location: New Well Street Number: Street Name: 26 MOCO RD Please specify well type: Building Lot#: Assessor's Map#: Domestic --� 215 Assessor's Lot#: ZIP Code: Number Of Wells: 090 02668 Cityrrown: Well Location BARNSTABLE In public right-of-way: GPS t a Yes C No North: West: 41.69026 70.34872 Subdivision/Property/Description: Mailing Address: F:click here if same as well location addres Property Owner: Street Number: Street Name: TAYLOR ROSSICONE 26 MOCO RD City/Town: State: Engineering Firm: BARNSTABLE MASSACHUSETTS ZIP Code: 02668 Board of health permit obtained: f' Yes r,Not Required Permit Number: Date Issued: W2021065 11/08/2021 l.._....._._................................................................. Massachusetts Department of Environmental Protection ' Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) ' Well Driller - General Well Form DRILLING METHOD Overburden Bedrock Auger I Choose Bedrock— WELL LOG OVERBURDEN LITHOLOGY Drop in drill Extra fast or slow Loss or addition From(ft) To(ft) Code Color Comment stem drill rate of fluid 0 20 Medium Sand • Brown N f'Fast(7 Slow Loss YES NO �_ Loss Addition 20 25 i Medium Sand Brawn a� YES NO 'Fast C`.5 low Loss Addition ................ .............. �� �� �— Brown — TRACE GRAVEL ' (—,Fast C'Slow 25 45 Medium Sand y YES NO Loss Addition — - ----- --�• TRACE GRAVEL (", C' C"• ("' 45 50 71IMedium Sand Brown i F FF. ('SiowYES ND � Loss Addition C ( ...._.... (. { 50 60— Silty Sand _J Brown YES'ND Fast C4 Slow Loss Addition 60 80 Fine To Coarse S i* Brown I ('Fast( Siow YES NO � Loss Additicn WELL LOG BEDROCK LRNOLOGY __..__. Drop in Extra fast or Loss or Visible Rust Extra From(ft) TOM) Code Comment addition of Large drill stem slow drill rate fluid Staining Chip s Choose Loss Code rYEs—Noli LF�r--sL�Slo-j. ADDITIONAL WELL INFORMATION Developed Yes G No Disinfected Total Well Depth 80 Depth to Bedrock Surface Seal Type lNone racture Enhancement C'3Yes l No CASING )�Is Casing above ground? From To Type Thickness Diameter Driveshoe Polyvinyl Chloride Schedule 40 .•'- C — Y? SCREEN r€No Screen From To Type Slot Size Diameter 77 80 Stainless Steel Well Point 11+ 0.012 WATER43EAPJNG ZONES r7—DRY WELL From To Yield(gpm) f Massachusetts Department of Environmental Protection Bureau of Resource.Protection—Well Driller Program Well Completion Reports(General) 55 ILO--] 112 PERMANENT PUMP(IF AVAILABLE) Wire Constant S ed Pump Description � Horsepower Submersible 3/4� Pump Intake Depth(ft) 76 Nominal Pump Capacity(gpm) 10 ANNULAR SEAL/FILTER PACK ................................................................................. From To Material 1 Weight Material 2 Weight Water Batches Method Of (gal) (count) Placement Choose Material ( 1 —� --� ( ---— �— Choose Matenal Choose One WELL TEST DATA Date Method Yield(gpm) Time Pumped Pumping Level(ft Time To Recover Recovery(ft (HH:MM) BGS) (HH:MM) BGS) 11/09/2021 CConstant Rate Pump � 12 01:30� 56 00:01 55 WATER LEVEL Date Measured Static Depth BGS(ft) Flowing Rate(gpm) 11/09/2021 55 [12 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete and accurate to the best of my knowledge. Supervising Driller DESMOND DEREK Monitoring[M] Signature III, DrillerG00DWIN Registration# 764 THOMAS,E DESMOND WELL Date Job Complete Firm DRILLING INC. Rig Permit# 025 11/10/2021 NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. f ENVIROTECH LABORATORIES,INC. MA CERT: NO.: M. -MA 063 8 Jan.Sebastian Drive Unit 12 Sandwich,MA 02563 (508)888-6460 .1-800-339-6460 FAX(508)888-6446 Client Nam: Desmond Well.Drilling Location: Address: PO Box 2783 26 Moco Road Orleans, MA West Barnstable,MA 02653 Lab Number: DW-215362 Collected By: DWD Date Received: 11/10/21 Sample Type: New Well Well Specs: 4°PVC 80/55 ia,nwa"'*I ovation S'tiurce �'``%Date t RlleCtE{l° T1:77Qedll zed ., (1►tri {tS b�,r�`' 3 t ^ d at!aa�Rilaii� -01" w. Analysis Requested units Rccoritrrtended Limits ;Analysis Result; Method Date Analyzed Analyzed ily . "Total Coliform CFU/100mL 0 .... 0 SM9222B 11/10/2021 SD @ 1445 . pH" pH units 6 5-8.5 6.13 SM 4500-H B 11/10/2021 SD .- Specific Conductances umhos/cm 500 111 EPA 120 1 11/10/2021 SD ............-_. . .. .. .._,.,. ..-, N.,,.m._mm_ _. _ EPA300.0 "..�11 ....... , Nitrite-N mg/L 100 __. <0.006 /10/2021 SD Nitrate-N m /L 10.0 � 1.00 EPA.-300.0 11/ ._. _ _ g 10I2021 SD Sodium mg/L 20.0 5 EPA200,7 11/1 1/2021 KB ._m . ., Total Iron mg/L 0.3 0.02 EPA 200„7 11/11/2021 KB . _...-..... _.m. .._.. .,.._. r... .. __,.. _ Manganese mg/L 0.05 <0.005 EPA 200.7 11/11/2021,... KB _. - ...._ . .... .. .. _._._ ....... .. Volatile Organic Compounds* ug/L See comment. See Attached EPA 524,2 11 V2021 NEC Comments: pH is below recommended limit and may have corrosive characteristics. *2-Butanone and acetone are found in the PVC glue used for well construction. *Limits:2 Butanone 4000 ug/L,Acetone 6300 ug/L *Trace to low levels of chloroform are occasionally detected in ground water in coastline areas. All samples were analyzed within the established guidelines of US EPA approved methods with all requirements met, unless otherwise noted at the end of a given sample's analytical results. We certify that the following results are true and accurate to the best of our knowledge. Water meets EPA standards and is suitable for drinking for parameters tested. Date 11/12/2021 Ronald A Saari Laboratory Director BRL=Below Reportable Limits *See Attached Page 1 of 1 ❑Certification is not available for this analyze for potable water samples.. New England Chromachem 6 Nichols Street Salem,MA 01970 978-744-6600 Sample Information EPA Method 524:2 4,:1 Rev Volatile Organic-Compound s in Water.._ 111305__ Client: 1 Envirotech Laborato ,Inc. Client ID: _'DW-215362 State: Liquid: Date Sam 11/09/21 Date Received:- ___ _ _ 11/11./21 Date Analyzed:_ 11/11/21 - _ MCE7, Regulated VOC's Results(ug/L) "'.(uglL) Unregulated VOC's Results(ugI 3 Benzene ND 5 Acetone`.. 1090 Carbon.Tetrachloride ND :._:: 5 , Bromoberizene NO 1,1-Dlchloroethene- NO 7 Bromochloromethane ND !1,2-Dichloroethane 'ND 5 Bromodichloromethane ND 1,2-Dichlorobenzene NO 600 Bromoform NO 1,40ich1orobenzene ND` - 5 ; Bromomethane .. NO Trichloroethene....- _ ND 5 2=Butanone 1539 1,1,1-Trichloroethane ,NO 200 N-Bu benzene ND Vinyl Chloride NO 2 Sec-Bu benzene ND Chlorobenzene ND 100 Tert-But: benzen..e...: _ — NO - - - 0 ;Chlo NDcis-12-d-hloothene ND e trans-1;2-dichloroethene.:.: ND - , 100. _ Chloroform 2.05 1;2-Dichloropropane NO 5 Chloromethane NO Eth Ibenzene NO 700 I 2-Chlorotoluene ND Styrene ND 100 4-Chlorotoluene _ND Tetrachloroethene :ND 5 Dibromochloromethane Toluene __ _ - m NO _,. ,1000; 12-Dibromo-3-Chloropropane ND Xylenes(TotalL JND 10000 1,2-Dibromoethane ND Methylene Chloride NO 5 Dibromomethane ND 1,2,4 Trichlorobenzene ND. -: 70 1,,3-Dichlorobenzene. ND 1,1,2-Trichloroethane_ — ND__ >Dichlorodifluoromethane ND - - - � 1,1-Dichlaroethane ND 'Acetone Detection Limit=10 ug/L 1,3-Dichloropropane ND NO=<Method Detection Limit 2,2-Di6hloro ro ane ND NA=Not Analyzed 1,1-Dichloropropane ": ND MRL=0.5 ug/L cise-1,3-Dichloro ropene _:. ND Dilution Factor= 1 trans-1.,3-Dichloropropene ND Hex achlorobutadiene ND Isopropylbenzene NO. P-lsoprapyttoluen.e ND Methyl-tert-butyl ether ND Naphthalene ND N-Prop benzene ND 1 1,12-letrachloroethane.' ND 11,2,2-Tetrachloroethane' ND 1,2,3-Trichlorobenzene ND 3 ; Trichlorofluoromethane ND 1,2,3-Trichloropropane ND 12,4-Trimethylbenzene ND, _ _._.__::.t. _:- -- 1',3,5-Trimeth .Ibenzene ND Burro ate Standard Recoveries_ Benzene-d6 100 _ MCL TTHM's=80 ug/L 4-Bromofluorobenzene 1.04 Method Detection Limit=0.5 ug/L 1,2-Dichlorobenzene-d4 102 Analysis performed per 31OCMR42 Electronically signed and approved by Mr Bruce A.Bornstein,Lab Director Date: 11/12/2021 No. Fee BOARD OF HEALTH TOWN OF BARNSTABLE TippYicatiou _for Vern Cougtructiou permit Application is hereby made for a permit to Construct), Alter( ), or Repair( an individual well at: 2c� N��cbVV- 15MO&W Location-Address , Assessors Map and Parcel TAN [or 1' oQ s Cone) 2te Maco KJ lj- 51CA) nz.Ca(a Owner f Address -I rn®n�► wp-o -bri I li w , Inc, Vd 9ox �`7��, or1 O-C�r c, �* 02-cos3 Installer-Driller j Address Type of Building / Dwelling J Other-Type of Building No. of Persons Type of Well9(,#410 t 1 Capacity_ ot��pin,— Purpose of Well ,pr Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town,of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Cert�'=ofCompliance has been issued by the Board of Health. Signed,N `.. �� S kozi D Application Approved By , at 2 ate Application Disapproved for the following reasons: Date Permit No. 7, 1 j r G' Issued t 2/ Date ------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed M, Altered( ), or Repaired( ) by on r I vie-, Installer at 2(� M oC-0 r-yl _ 11 �QYVl —,{� LC,-- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private WelfMotection Regulation as described in the application for Well Construction Permit No. VJ1114 Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector ' {� w Oi .it'll ,:•tl No. ' W Z,Q�,( ob i` Fee BOARD OF HEALTH TOWN OF BAR=NSTABLE 2pprication -for lVerr Construction Permit Application is hereby made for a permit to Constructy); Alter( ), or Repair( an individual well at: Location'-Address Assessors Map and Parcel �a .far t>s 1 C Oh f(,� MoCU �� . w r arty-i�Q b C.)2- Owner Address n c1 V I 1 r I I 1 nL G`'�U :cox o27 - (� lr ct r � , 02 Installer-Driller c Address Type of Building Dwelling Other-Type of Building ; ` No. of Persons Type of Well C'� �� ��IV Ll + Capacity G "� Purpose of Well Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certi ate of Compliance has been issued by the Board of Health. Signed J, l S(20 .# Date Application Approved By r fAl2� Date Application Disapproved for the following reasons: Date Permit No.,, )74)7/1 ' b'� 3 Issued I 1 MI Date --rr----rrr-------------------r---------- r---rrr---------------r—r—.----- —r--rr---rw BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed(4, Altered( ), or Repaired( t ) Installer (P V b tC .at has been installed in accordance with the provisions of the Town)of Barnstable Board of Health Private Wel�'P otection Regulation as described in the application for Well Construction Per �Permit No. U.q ' - U.� Dated � 2.-/ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector a ----- --r---- ---- -------- 3xa---------------- mar-.e -------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Vern Con5truction Permit , No. [A it l �fl Fee �J Permission is hereby granted to -:. CY l ;� I ► , r1�, Installer to Construct, } Alter ), or R,ep.{air( .) an indivjiidua�l,well at: Street as shown on the application for a Well Construction Permit No. 2,,N t'',)I/ ,— Dated Date �. !/ � ' l Approved By w _ C�A1ZtZ E T7'S ION D EXISTINl.I 4'n 1Z y ILJ- I - �.. l�.. { "ha' _ � ✓ i. WOODEN POGIC--\ � f�TION OF DOG�L LV. I ' LC:L_S p 4 �4 --- I g 20' 2'x 6' GINCI 6EG71 ON OF DOaG, �1 4"x 4' PO$T5� _ D'eGL ` EDE PLAT FO'Z.'t -% �_.TION a .. a s n�TFOIZT 1 Oc=f pI L e'x a vosTs z. _ • _ _ -.... - --._6d r-�+'I ICE D-cGIC o' I " 4 70 5T�14GE1Z i ;O ST¢IN[IEfLS� 74 /O LOT 7Z ., ST EPZ NOD �% U 17,ZSOt 5F `.74 \ S 4 D`_G' i ---\ i 5.4 DEGIG G1,pTFOZ"I E µ ST SIN EIZS ,I O ST 21NCJE2'- 8"v. 8" Fo":6 �.eo 2�-�TINGI CN(1¢Ol:"ACi CAa10N \ DO HOUSE NO.26 MOCO ROAD -0 �P TOWN MAP.215 PARCEL 9 0, \ EXISTING DOCK 6 PROPOSED PLATFORM LOCATED IN WEST BARNS TABLE - MASS. PREPARED FOR KENN SSICONE -- _. ....... Op _.. PLAN NO.10209E SCAL _........ 44 E. AS NOTED TH ' FQCO. 30• FILE NO.355BA DATE-TE.- OCT.20. 1998 DRAWN 8Y.'ELY - D-61BA /z� ��rr ante 1 CAPE 6 ISLANDS ENGINEERING 133 FALMOUTH RD. SUITE 2E. MASHPEE - MASS. i ro -rz 74 �' LOT .. I ` 7Z 1 tNG i 17, ZSO+ 5F e r 0 O �..\ Plo qq+ J �V' s ELL/�4 ; air Imo+ 0 / �y MC" prop oCo qa. COMMONWEALTH OF MASSACHUSETTS y� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON. MA 02108 617-292-5500 A*ILLIAM F.WELD TRUDY COXE Governor Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A � / CERTIFICATION K.b Elizabeth Rossicone Property Address: Ttl%-Moto d, W Barnstable Address of Owner: p ►tY p �^ 7^�� 9 Fell Street Date of Inspection: (If different) Wakefield, MA 01 880 Name of Inspector: Wm E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Service Mailing Address: PO Box 1089 Centervi 1 1 P,, GA 02632 Telephone Number,, 5 0 8 } 7 7 5-R j Z , CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this addre ation below is true, accurate and complete as of the time of inspection. The inspection was performed on my training and experttreportetd oper function and maintenance of on-site sewage disposal systems. The system:Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving ority Fails Inspector's Signature: A✓� 1, 4 Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, Or D: A] SYSTEM PASSES: 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indic to yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:ltwww.magnet.state.ma.usldep ej Printed on Recycled Paper r F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Moco Rd, W Barnstable Owner: ROssicone Date of Inspection: I-- ?- 9 F B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced ^- The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FUR HER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the ublic health, safety and the environment. 1) S STEM'WILL PASSIINLtSS BOARD'OF;HEA'LTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER HICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet.of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SY TEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT T E SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE E VIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more.from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) O HER (revised 04/25/97) Page 2 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Moco Rd, . W Barnstable Owner: Rossicone Date of Inspection: D] SYSTEM FAILS: You ust indicate ei;-,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes o Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than li2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You mus indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well) The o ner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requi ements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 Moco Rd, W Barnstable Owner: ROsslcone Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes / No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 Moco Rd, W Barnstable Owner: Rossicone Date of Inspection:-2,-9—9 7- FLOW CONDITIONS RESIDENTIAL: Design flow: 33 V g.p.d./bedroom for S.A.S. Number of bedrooms: h/ Number of current residents: Garbage grinder (yes or no):�L—O Laundry connected to system (yes or no): � Seasonal use (yes or no):%^&S Water meter readings, if a'vailable (last two (2) year usage (gpd): NSA Well Water Sump Pump (yes or no):Ze—_6 Last date of occupant}: - Cj`,q COMMERCIAL/INDUSTRIAL: Type of tablishment: Design flo gallons/day Grease tra present: (yes or no)_ Industrial ante Holding Tank present: (yes or no)_ Non-sanitaly waste discharged to the Title 5 system: (yes or no)_ Water me er readings, if available: Last dL: (Describe) occupancy: OTHE Last doccupancy: GENERAL INFORMATION, PUMPING RECORDS and source of information: zt,I System p16mped as part of inspection: (yes or no)_1/ 6 If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other , APPROXIMATE AGE of all components, date installed (if known) and source of information:,? 2 -4 Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 MOCO Rd, W Barnstable Owner: Rossicone Date of Inspection: BUILDING SEWER: (L cate on site plan) Depth below grade: Materia of construction: _cast iron _40 PVC _other (explain) Distance rom private water supply well or suction line Diameter Comments (condition of joints, venting, evidence of leakage, etc.) SEPTIC TA K:_ (locate on ite plan) Depth bel w grade: Material f construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank metal, 'list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensio s: Sludge de the Distance fr m top of sludge to bottom of outlet tee or baffle: Scum thick ess Distance fro top of scum to top of outlet tee or baffle: Distance fro bottom of scum to bottom of outlet tee or baffle: How dimen ions were determined: Comments: (recommen ation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, e idence of leakage, etc.) GREASE TRAP: (locate n site plan) Depth b low grade: Material f construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensio s: Scum thic ness: Distance f om top of scum to top of outlet tee or baffle: Distance f om bottom of scum to bottom of outlet tee or baffle: Date of la t pumping: Comme s: (recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integri evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Moco Rd, W Barnstable Owner: ROsslcone Date of Inspection: ; -7— 9 5 TI HT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (Iota on site plan) Depth low grade: Material f construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensio s: Capacity: gallons Design fl w: gallons/day Alarm le el: Alarm in working order _ Yes; _ No Date of revious pumping: Comm nts: (cond" on of inlet tee, condition of alarm and float switches, etc.) DISTRI UTION BOX:_ (locate n site plan) Depth of quid level above outlet invert: Comments: (note if leve and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CH MBER:_ (locate o site plan) Pumps in orking order: (Yes or No) Alarms in orking order (Yes or No) Comments: (note conditi n of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Moco Rd, W Barnstable Owner: Rossicone Date of Inspection: X $— SOIL ABSORPTION SYSTEM (SAS): 11 ate on site plan, if possible; excavation not required, but.may be approximated by non-intrusive methods) If no determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comm I (note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: _ (locate on site plan) Number and configuration: .x Lo Depth-top of liquid to inlet invert: Y>/Z h Depth of solids layer: Depth of scum layer: Dimensions of cesspool:,,_ Materials of construction: wot k S Indication of groundwater: .& D inflow (cesspool must be pumped as part of inspection) ji Comments: (note condition of oil, signs of hydra lic failure, level of ponding, condition of vegetation, etc.) 6 0 ® A'% -i / AC_h Sr 5S AA 62 PRI :_ (locat on site plan) Mate ials of construction: Dimensions: Dep of solids _ Co ments: (no a condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 MOCO Rd, W Barnstable Owner: ROSsiCOne Date of Inspection: p`x SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) iN✓G l R o �— /7 F a I e L�r /o (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Moco Rd, W Barnstable Owner: Rossic0�e Date of Inspection: ,7,^7—4 .k, Depth to Groundwater 30 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record I// Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own /words how you established the High Gro ndwater Elevation. (Must be completed), S /vo m (7 LZ d dj t� < �O n I h6 Usl- (revised 04/25/97) Page 10 of 10 A